How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework

Purpose. Under the national framework law in Sweden, all eligible people should have equal chances of receiving vocational rehabilitation. We aimed to review the evidence on (1) whether access to vocational rehabilitation is equitable in practice and (2) whether the outcomes vary for different groups in the population. Method. Systematic review of studies in Sweden that reported diagnostic or socio-demographic characteristics of people offered or taking up rehabilitation programmes and outcomes of such programmes for different diagnostic and socio-demographic groups. Searches of 11 relevant electronic databases, 15 organisational websites, citation searching and contact with experts in the field, for the period 1990–2009. Results. A total of 11 studies were included in the final review, six of which addressed review question (1) and seven addressed review question (2). All the six observational studies of access reported biased selection into vocational rehabilitation: greater likelihood for men, younger people, those with longer-term sick leave, those with lower income, employed rather than unemployed people and those with musculoskeletal and mental disorders or alcohol abuse. Having had a rehabilitation investigation also increased the likelihood of receiving vocational rehabilitation. Differential outcome of rehabilitation was reported in seven studies: outcomes were better for men, younger people, employed individuals, those with shorter sick leave and those with higher income. Selection into vocational rehabilitation was perceived as important for successful outcomes, but success also depended on the state of the local labour market. Conclusions. There is evidence of socio-demographic differences in access to and outcomes of vocational rehabilitation in Sweden, even though the national framework law is meant to apply to everyone. Few studies have deliberately measured differential access or outcomes, and there is a need for this kind of equity analysis of population-wide policies. Studies evaluating the effects of vocational rehabilitation must consider selection into the programmes for adequate interpretation of impact results

Health inequalities between lone and couple mothers and policy under different welfare regimes – The example of Italy, Sweden and Britain

This study examines the welfare state arrangements and social policy, living conditions and health among lone and couple mothers in three contrasting policy environments: Italy, Sweden and Britain. These countries fall into distinctive family policy categories. Data were drawn from representative national household interview surveys. The findings highlight both similarities and differences. Lone mothers had significantly worse health than couple mothers in all three countries, were more likely to suffer material disadvantage and were much more likely to be smokers. They could be considered a disadvantaged group in particular need in all three countries, irrespective of the policy regime. It is the differences between countries, however, in the experiences of lone and couple mothers that indicate that the prevailing policy regime really does matter. There were telling differences in the prevalence of lone motherhood, their composition, rates of joblessness, poverty and health status of lone mothers in relation to couple mothers in each country. These may be traced back to the main policy regimes of each country, but also partly reflect culture and traditions. The study illustrates an emerging approach to investigating the health inequalities impact of complex social policy contexts. The experiences of lone mothers as a group may serve as a ‘litmus’ test of how each family policy system is operating and offer an early warning of adverse impacts when policies change

Helping chronically ill or disabled people into work: what can we learn from international comparative analyses?

This project has added to knowledge in five main areas: It has mapped the range and types of policies and interventions that have been implemented in Canada, Denmark, Norway, Sweden and the UK that may influence employment chances for chronically ill and disabled people. By doing so it has added to understanding about what has actually been tried in each country and what might be considered in others. It has refined a typology of the focussed interventions that have been identified, based on the underlying programme logic of the intervention, which aids strategic thinking about national efforts to help chronically ill and disabled people into work. It has produced systematic reviews of the impact of the focussed interventions on the employment chances of chronically ill and disabled people and demonstrated the use of the typology in helping to interpret the results of the evaluations. The project’s empirical analyses of individual-level data have identified how chronically ill people from different socio-economic groups have fared in the labour markets of the five countries over the past two decades. It has then tested these findings against hypotheses about the impact of macro-level labour market policies on chronically ill people to provide insights into the influence of the policy context. The project has contributed to methodological development in evidence synthesis and the evaluation of natural policy experiments. By studying a small number of countries in great depth, we gained greater understanding of the policies and interventions that have been tried in these countries to help chronically ill and disabled people into work, against the backdrop of the wider labour market and macro-economic trends in those countries. We then integrated evidence from the wider policy context into the findings of systematic reviews of effectiveness of interventions, to advance interpretation of the natural policy experiments that have been implemented in these countries

To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems

Background Reductions in the eligibility requirements and generosity of disability benefits have been introduced in several Organisation for Economic Cooperation and Development (OECD) countries in recent years, on the assumption that this will increase work incentives for people with chronic illness and disabilities. This paper systematically reviews the evidence for this assumption in the context of well-developed welfare systems. Method Systematic review of all empirical studies from five OECD countries from 1970 to December 2009 investigating the effect of changes in eligibility requirements or level of disability benefits on employment of disabled people. Results Sixteen studies were identified. Only one of five studies found that relaxed eligibility was significantly associated with a decline in employment. The most robust study found no significant effect. On generosity, eight out of 11 studies reported that benefit levels had a significant negative association with employment. The most robust study demonstrated a small but significant negative association. Conclusion There was no firm evidence that changes in benefit eligibility requirements affected employment. While there was some evidence indicating that benefit level was negatively associated with employment, there was insufficient evidence of a high enough quality to determine the extent of that effect. Policy makers and researchers need to address the lack of a robust empirical basis for assessing the employment impact of these welfare reforms as well as potentially widerpoverty impacts

Association between neighbourhood characteristics and antidepressant use at older ages : a register-based study of urban areas in three European countries

Background Research evidence on the association between neighbourhood characteristics and individual mental health at older ages is inconsistent, possibly due to heterogeneity in the measurement of mental-health outcomes, neighbourhood characteristics and confounders. Register-based data enabled us to avoid these problems in this longitudinal study on the associations between socioeconomic and physical neighbourhood characteristics and individual antidepressant use in three national contexts. Methods We used register-based longitudinal data on the population aged 50+ from Turin (Italy), Stockholm (Sweden), and the nine largest cities in Finland linked to satellite-based land-cover data. This included individual-level information on sociodemographic factors and antidepressant use, and on neighbourhood socioeconomic characteristics, levels of urbanicity, green space and land-use mix (LUM). We assessed individual-level antidepressant use over 6 years in 2001-2017 using mixed-effects logistic regression. Results A higher neighbourhood proportion of low-educated individuals predicted lower odds for antidepressant use in Turin and Stockholm when individual-level sociodemographic factors were controlled for. Urbanicity predicted increased antidepressant use in Stockholm (OR=1.02; 95% CI 1.01 to 1.03) together with more LUM (OR=1.03; 1.01-1.05) and population density (OR=1.08; 1.05-1.10). The two latter characteristics also predicted increased antidepressant use in the Finnish cities (OR=1.05; 1.02-1.08 and OR=1.14; 1.02-1.28, respectively). After accounting for all studied neighbourhood and individual characteristics of the residents, the neighbourhoods still varied by odds of antidepressant use. Conclusions Overall, the associations of neighbourhood socioeconomic and physical characteristics with older people's antidepressant use were small and inconsistent. However, we found modest evidence that dense physical urban environments predicted higher antidepressant use among older people in Stockholm and the Finnish cities.Peer reviewe

socioeconomic inequalities in suicide mortality in european urban areas before and during the economic recession

Abstract Background Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis. Methods This ecological study of trends was based on three periods, two before the economic crisis (2000–2003, 2004–2008) and one during the crisis (2009–2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model. Results Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24–3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35–0.68) in the third period. Conclusions Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied

The impact of longstanding illness and common mental disorder on competing employment exits routes in older working age: A longitudinal data-linkage study in Sweden

OBJECTIVES: Comorbidity is prevalent in older working ages and might affect employment exits. This study aimed to 1) assess the associations between comorbidity and different employment exit routes, and 2) examine such associations by gender. METHODS: We used data from employed adults aged 50-62 in the Stockholm Public Health Survey 2002 and 2006, linked to longitudinal administrative income records (N = 10,416). The morbidity measure combined Limiting Longstanding Illness and Common Mental Disorder-captured by the General Health Questionnaire-12 (≥4)-into a categorical variable: 1) No Limiting Longstanding Illness, no Common Mental Disorder, 2) Limiting Longstanding Illness only, 3) Common Mental Disorder only, and 4) comorbid Limiting Longstanding Illness+Common Mental Disorder. Employment status was followed up until 2010, treating early retirement, disability pension and unemployment as employment exits. Competing risk regression analysed the associations between morbidity and employment exit routes, stratifying by gender. RESULTS: Compared to No Limiting Longstanding Illness, no Common Mental Disorder, comorbid Limiting Longstanding Illness+Common Mental Disorder was associated with early retirement in men (subdistribution hazard ratio = 1.73, 95% confidence intervals: 1.08-2.76), but not in women. For men and women, strong associations for disability pension were observed with Limiting Longstanding Illness only (subdistribution hazard ratio = 11.43, 95% confidence intervals: 9.40-13.89) and Limiting Longstanding Illness+Common Mental Disorder (subdistribution hazard ratio = 14.25, 95% confidence intervals: 10.91-18.61), and to a lesser extent Common Mental Disorder only (subdistribution hazard ratio = 2.00, 95% confidence intervals: 1.31-3.05). Women were more likely to exit through disability pension than men (subdistribution hazard ratio = 1.96, 95% confidence intervals: 1.60-2.39). Common Mental Disorder only was the only morbidity category associated with unemployment (subdistribution hazard ratio = 1.70, 95% confidence intervals: 1.36-2.15). CONCLUSIONS: Strong associations were observed between specific morbidity categories with different employment exit routes, which differed by gender. Initiatives to extend working lives should consider older workers' varied health needs to prevent inequalities in older age

Social differences in avoidable mortality between small areas of 15 European cities : an ecological study

Peer reviewe

Does non-employment contribute to the health disadvantage among lone mothers in Britain, Italy and Sweden? Synergy effects and the meaning of family policy.

This study analyses self-rated health and non-employment and potential synergy effects among lone and couple mothers aged 25–59 in Britain, Sweden and Italy, representing different family policy categories using data from national surveys (2000–2005). Synergy effects on health were calculated by synergy index. Non-employment only marginally contributed to the excess risk of poor health among lone mothers but there were synergy effects between lone motherhood and non-employment in all three countries, producing a higher risk of poor health than would be expected from a simple addition of these exposures. Results are discussed in relation to the different family policy and living contexts

Trends in poverty risks among people with and without limiting-longstanding illness by employment status in Sweden, Denmark, and the United Kingdom during the current economic recession – a comparative study

BACKGROUND: Previous studies have found higher employment rates and lower risk of relative poverty among people with chronic illness in the Nordic countries than in the rest of Europe. However, Nordic countries have not been immune to the general rise in poverty in many welfare states in recent decades. This study analysed the trends in poverty risks among a particularly vulnerable group in the labour market: people with limiting-longstanding illness (LLSI), examining the experience of those with and without employment, and compared to healthy people in employment in Sweden, Denmark and the United Kingdom. METHODS: Cross-sectional survey data from EU-SILC (European Union Statistics on Income and Living Conditions) on people aged 25–64 years in Sweden, Denmark and the United Kingdom (UK) were analysed between 2005 and 2010. Age-standardised rates of poverty risks (<60% of national median equalised disposable income) were calculated. Odds ratios (ORs) of poverty risks were estimated using logistic regression. RESULTS: In all three countries, non-employed people with LLSI had considerably higher prevalence of poverty risk than employed people with or without LLSI. Rates of poverty risk in the UK for non-employed people with LLSI were higher than in Sweden and Denmark. Over time, the rates of poverty risk for Swedish non-employed people with LLSI in 2005 (13.8% CI=9.7-17.8) had almost doubled by 2010 (26.5% CI=19.9-33.1). For both sexes, the inequalities in poverty risks between non-employed people with LLSI and healthy employed people were much higher in the UK than in Sweden and Denmark. Over time, however, the odds of poverty risk among British non-employed men and women with LLSI compared with their healthy employed counterparts declined. The opposite trend was seen for Swedish men: the odds of poverty risk for non-employed men with LLSI compared with healthy employed men increased from OR 2.8 (CIs=1.6-4.7) in 2005 to OR 5.3 (CIs=3.2-8.9) in 2010. CONCLUSIONS: The increasing poverty risks among the non-employed people with LLSI in Sweden over time are of concern from a health equity perspective. The role of recent Swedish social policy changes should be further investigated